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Dr. William Winkenwerder interview

Monday, November 29th, 1999 - 20:00

Phrase:

"We see the healthcare challenge as being how to protect all of America, the military and civilian population."

Mr. Lawrence: Good morning and welcome to The Business of Government Hour. I�m Paul Lawrence, partner-in-charge of The IBM Center for The Business of Government. We created the Center in 1998 to encourage discussion and research into new approaches to improving government effectiveness. You can find out more about the Center by visiting us on the web at www.businessofgovernment.org.

The Business of Government Hour features a conversation about management with a government executive who is changing the way government does business. Our special guest this morning is Dr. William Winkenwerder, Assistant Secretary of Defense for Health Affairs, in the U.S. Department of Defense. Good morning.

Dr. Winkenwerder: Good morning. Nice to be here.

Mr. Lawrence: Thanks for joining us, Bill.

And also joining us in our conversation is Mike Perry.

Good morning, Mike.

Mr. Perry: Good morning.

Mr. Lawrence: Well, Bill, let�s start out by finding out more about military medicine. Would you give us a sense of the mission of the Department of Health Affairs?

Dr. Winkenwerder: Paul, our mission is to provide for all of our military commands and for all the missions of the Department of Defense, their health support, their medical support, to ensure that our troops are medically ready and that when we have operations, we have the ability, the capability, worldwide, to care for them. That�s what we call our readiness mission.

We have another mission, and that is to take care of the everyday health care needs of those same service members as well as their families and dependents, and also military retirees who have at least 20 years of experience and then have a lifetime benefit. So we have a dual mission, an unusual type of arrangement, for any organization.

Mr. Lawrence: Now I�m told you�re the top doc, as I understand it. Could you describe your roles and responsibilities related to this mission?

Dr. Winkenwerder: My role is to serve as the chief health and medical advisor to the Secretary of Defense. It is also to have the responsibility for all policy with respect to health issues and medical issues within the Department of Defense, and all the program oversight -- budgets and resources for all of our various components in the military health system, and that includes Army, Navy, Air Force, and Marines, and the medical organizations within all of those.

It also includes our, what we call, TRICARE Management Program, or TRICARE Management Activity. It�s our health insurance coverage plan that covers everybody, and also within the military health system, we have a medical school that trains medical students and nurses, and we do lots of health care research and medical research. So my responsibilities are to have oversight for all of that.

Mr. Lawrence: How would you describe the size of what you just described; staffing, budget?

Dr. Winkenwerder: It�s a very large organization and large by government standards even; certainly large by private sector standards. Our annual budget this year is about $28 billion, and we have working, within the military health system, about 130,000 individuals. A little bit over 90,000 of those are military uniformed members, and almost 40,000 are civilians, and that does not include, I might add, the reservists and guardsmen. So we actually are probably operating with a bit more than that right now because of reservists and guardsmen who�ve been called up for duty.

Mr. Perry: I�m proud to say that I�m a retired military member and as such, I am a beneficiary of your services.

Dr. Winkenwerder: Great.

Mr. Perry: I�d like to know a bit more about other beneficiaries; how many there are and so forth.

Dr. Winkenwerder: Within the military health system?

Mr. Perry: Yes.

Dr. Winkenwerder: Yes.

Well, certainly the family members are very, very important. One of the messages we hear time and again -- I�m sure it�s a message that you were provided when you were in the Service -- and that is one of the greatest concerns for Service members when they go off on operations is their families; will their families be taken care of, and so we can say emphatically yes, and that�s a top priority for us.

So we care for those family members and dependents and also retirees; those retirees of any branch of the military who have 20 years of experience, and by that 20-year experience, gain a lifetime benefit, and so that benefit goes -- until they reach the age of 65, and then just recently, because of the law that the Congress passed, those who are over 65 are covered by Medicare, of course, but in the past, people had to pay for their pharmaceuticals and other cost shares, either through their employer or out of their pocket. We created an additional benefit called TRICARE for Life, which takes care of all those other expenses, which, in some cases, can be substantial. So actually, we have had a population of people in the United States, for a couple of years now, over 65, Medicare eligibles, who do have a drug benefit, and that�s the military.

As we today talk about the whole issue of Medicare and changing that benefit, we had to create a new drug benefit.

Mr. Lawrence: Can you give us order of magnitude -- sorry to put you on the spot here -- in terms of percentage of active duty, service members, family members, then retirees.

Dr. Winkenwerder: Our entire covered population is just under 9 million right now, and so that�s a large group of people. 1.4 million of those are active duty. We have about 160,000 on top of that now who are reservists or guardsmen who�ve activated. So they�re eligible and they have these benefits when they come on to active duty.

The family members and dependents I think bring the number to somewhere between three and four million, and then the remainder are retirees. We actually have quite a large number of retirees in our program.

Mr. Perry: Could you tell me a bit about your personal experience?

Dr. Winkenwerder: Sure. I�d be glad to.

I�m a physician by background and training. I�m an internal medicine, primary care doctor, and sought to practice medicine initially. That was my plan, to return to my hometown. Those plans changed as I learned more about health care, the health care system, and I got interested in how hospitals and health care systems worked, and sought some additional training for that, and went to business school after I finished all my medical training; practiced medicine for several years in a primary care practice, and then with that interest in management and economics and policy, sought opportunities as an administrator, and served for two or three different organizations; most recently, before I came here to Washington, with BlueCross-BlueShield of Massachusetts there in Boston, and prior to that, I was in Atlanta for several years and was with Emory University.

Mr. Perry: How do you think your medical background has helped you run your agency?

Dr. Winkenwerder: Well, hopefully, it�s provided assistance to my role in many ways. As a physician, I think it�s always important to be sensitive to the patient and his or her needs and to always put that really at the top of the priority list, but as somebody who�s spent time studying and participating as an administrator and manager, I think one has to appreciate the challenges with organizing a system of care and coverage for a group of people and how to do that, and how to manage so that the outcomes are good; the outcomes that relate to high service, customer satisfaction, quality, and then, how do we do all that cost-effectively? And so I use every day both sets of experiences in the past, and that�s been helpful.

Mr. Lawrence: You�ve had a long career of working in the private sector dealing with health care issues and now you�re in the public sector. What are the similarities or the differences between the two sectors as they deal with health care issues?

Dr. Winkenwerder: There are many similarities and there are some differences. The similarities are that it�s health care and it�s about people. It�s about doing the right thing. It�s about quality medicine, good outcomes and satisfying patients and beneficiaries, and all those count. It�s very similar.

The things that are different would relate, I think, primarily to the way that, in government, everything you do is so visible and everything is open for second opinion, so to speak, at the policy level and at the administrator level, and we have an interested Congress, obviously. We have constituent and interest groups, and so there�s a need to attend to -- and actually do more than attend to; to actually relate with, inform continually, and bring into the process of decision-making all those constituent groups.

So I think in many ways this type of responsibility is more challenging than many, I�ll say, if not most in the private sector, because you have all these other concerns that go along with the visible responsibility in government.

Mr. Lawrence: That�s an interesting point, especially about the constituents.

How has the delivery of care changed, now that we have Service members actively engaged in armed conflict? We�ll ask Dr. William Winkenwerder of the Department of Defense to describe these changes and challenges when The Business of Government Hour returns.

(Intermission)

Mr. Lawrence: Welcome back to The Business of Government Hour. I�m Paul Lawrence, and this morning�s conversation is with Dr. William Winkenwerder, Assistant Secretary of Defense for Health Affairs, in the U.S. Department of Defense.

And joining us in our conversation is Mike Perry.

Mr. Perry: We hear about and read about Health Affairs and TRICARE Management Activity. Could you explain a bit about the differences between what these are?

Dr. Winkenwerder: Certainly.

Health Affairs is the office within the Office of the Secretary of Defense, part of his overall organization, that�s responsible for all programs and policies and budgets relating to health in the Department of Defense. TRICARE Management Activity is the name of the organization. It�s what we call a field activity. It�s like an operating division, if you will, of a corporate structure, and it is the organization that oversees the provision of the health plan, the health coverage plan, for all those roughly 9 million beneficiaries. So that�s the relationship between the two. TRICARE reports to the Office of Health Affairs.

Mr. Perry: Thank you. You mentioned earlier about TRICARE for Life. Could you speak to that a bit more and tell us where that�s heading?

Dr. Winkenwerder: Yes. TRICARE for Life is a program of enhanced benefits for military retirees of 65 and over that was passed by Congress in 2000 -- I believe the year was 2000. We began to implement it in 2001, and we�re a couple of years into that implementation now. It�s a wonderful set of benefits that includes coverage, very extensive coverage, for pharmacy expenses that people can obtain through a retail pharmacy, through a mail order pharmacy, or through going to the military hospital or clinic and picking up that prescription. And in addition, it covers some of the cost-sharing that Medicare would typically require. So it�s an excellent benefit and one for a very deserving population of people.

Mr. Lawrence: Bill, I�m curious about the balance that takes place with limited resources. We have many deployments throughout the world. The �ops tempo� for the medical community is high, and yet you need to deliver medical care in peacetime. How do you balance this?

Dr. Winkenwerder: It�s an ongoing challenge. It is a tough balance to continually monitor and to implement. We�re assisted in all of that by the reservists who can be brought into the system to back up, so to speak, those medical providers who might have to deploy, and we�ve done that twice here in the last two years, with Afghanistan and Iraq, obviously affecting more medical personnel with Iraq, but in that case, the term we use is backfill. We call up reservists to assume those responsibilities of the personnel who deploy.

Now, we also utilize our network of Purchase Care, because we have contracts with community hospitals and doctors. That�s the other part of our TRICARE program that I did not mention earlier, but in addition to our 75 hospitals and 460 clinics that are all staffed by military personnel, either uniformed or civilians, we have contracts with health plans -- private health plans -- who, just like a managed care plan, BlueCross plan, Aetna plan, the like, we contract with Humana, TriWest, Sierra, and Health Net. Those are four large health plan companies, and they, in turn, organize networks of community hospitals and doctors. So that network, which we call our TRICARE network, is available for our retirees and, in some cases, as a back-up network for the active duty and their family members. So when people deploy, we can use that network to provide care. And so we really have these two systems; our direct care that we own and operate and then our Purchase Care that we purchase in the community.

Mr. Lawrence: Could you give me a sense, as a manager, a type of decision you�re called in to make when the resources are sort of in play; you know, direct care, active duty, and how that plays out.

Dr. Winkenwerder: Well, one of the decisions we have to make, and it�s made in close consultation with the medical leaders, the Surgeons General of all of the Services, as well as the joint staff and the combatant commander, for example, General Franks and his staff, in the case of Iraq, is the level of medical support that is deemed necessary for the operation, and there are lots of people that get involved in that process, but at the end of the process, a decision has to be made as to what level of resources is required, and that ultimately falls on the desk of Secretary Rumsfeld, and he in turn delegates to me and to my office to review those health resources and to make judgments working with all those other parties as to whether it�s the appropriate amount and level of assets. Obviously, we work very closely with a number of people on those types of decisions.

Mr. Lawrence: And how about understanding the management challenges of backfill as people are asked to leave their other jobs and come to do that? What are we learning from that?

Dr. Winkenwerder: Well, an important message that I would want to convey is that we have a large number of excellent, not just physicians, but nurses and allied health personnel, people across the spectrum of health care, who are reservists and guardsmen, who do an outstanding job, and they�re doing an outstanding job today in Iraq as we speak, providing medical care because they also deploy into the theater. But what I would say is it�s an excellent group of people, provides a very strong capability for us, and we�re really glad they�re part of our overall system.

Mr. Perry: You gave us a very good explanation of the scope of Health Affairs. How do you see technology playing into that? Is it helping you meet the challenges of quality of care, for example?

Dr. Winkenwerder: Absolutely. It�s playing into what we do in a variety of ways, and let me just touch on two or three of the most important. We are embarking on what may be one of the most significant and comprehensive efforts ever undertaken with respect to the development and implementation of an electronic medical record system. There are really only a very few organizations that, because of the complexity involved in doing this, are at this time attempting this.

We are now in the early stages of implementing a fully comprehensive electronic medical record system. So we�re doing away with paper records, and all those records are going to be on computer. And we�re starting now; we�ll be implementing over the next two years. This effort, by the way, has taken about six or eight years to develop. It didn�t just happen, and we work with many experts in the private sector community, collaborating with a variety of leaders in the technology field. So that�s important.

I would also note that in terms of medical technology, medical treatments, we�re constantly looking at bringing new products into what we do. For example, in Iraq, we�re using a new type of clotting, an anti-hemorrhage kind of treatment, called Quick Clot, and it stops bleeding so rapidly that it has the ability save lives, and we know that many lives have been saved through the use of this new treatment, and that�s a treatment that, in the near future, will be out into the private marketplace. But we�re able to do research and bring new products into our sphere of activity that then end up in the private sector, and so I think that that�s good for us. It�s good for the rest of medicine.

Mr. Lawrence: In thinking about the descriptions of the records, I couldn�t help but think about the sort of classic argument about privacy and sort of the need to retain information. How did that get worked through in that example?

Dr. Winkenwerder: Oh, there�s a huge aspect of doing it the right way, and so there are extensive procedures to encrypt or to be able to make and keep private information. There are rules as to who can have access to the system, and then there is constant oversight with respect to actual physical security and other things, and we really watch all this very, very carefully. We�re very sensitive to it.

There�s also obviously the matter of informed consent, and people knowing that certain things are being stored in computers and that they�re being asked for personal information. We operate under the HIPAA law, the new law that I think much of the public is getting familiar with now, and certainly the medical community is in terms of it�s there to do many things, but among which is to guarantee protection of personal medical information.

Mr. Lawrence: For some time, the Department of Defense and the Department of Veterans Affairs have been working together to improve medical care. What progress has been made and what�s the status of their collaboration? We�ll ask Dr. William Winkenwerder of the Department of Defense to update us when The Business of Government Hour returns.

(Intermission)

Mr. Lawrence: Welcome back to The Business of Government Hour. I�m Paul Lawrence, and this morning�s conversation is with Dr. William Winkenwerder, Assistant Secretary of Defense for Health Affairs, in the U.S. Department of Defense.

And also joining us in our conversation is Mike Perry.

Mr. Perry: A few minutes ago, you mentioned HIPAA. That�s something that as you said, impacts both the civilian and the military world. Could you speak to that in a little more detail, please?

Dr. Winkenwerder: Sure. For our health plan, TRICARE, we have implemented the HIPAA standards with regard to electronic transaction, submitting claims, electronic claims, and we are compliant with that. With respect to the medical care side, not the insurance side but the medical care side, we�ve made many improvements to many of our information systems and business practices in order to implement the HIPAA standard of electronic transactions, being able to do billing electronically rather than with paper. That�s one of the requirements. Then there�s certain ways that claims need to be submitted in a standard format and so forth. So really, both sides of our system, the insurance side and the provision of care side, have had to make changes. And we�re coming along; we�re doing, we think, well in all of those fronts.

We�ve also, I might add, added a privacy officer for TRICARE, elevating the importance of that whole issue, and we�ve obviously had to conduct a considerable amount of training in education for our staff, both with TRICARE and within the direct care system of the Army, Navy, Air Force, and Marines. So it�s been a big, big set of activities that we�ve done, but we believe we�re on track.

Mr. Lawrence: Cost containment remains a driving focus within many government agencies, but you also have the added challenge of access to care, as well as quality of care. How do you manage all three of these challenges?

Dr. Winkenwerder: Well, it�s part of maintaining the balance that is required for any superior top-flight health care system. It�s a balance of cost and access and quality.

I have a view that spending more money does not necessarily always lead to better outcomes or better quality. Certainly, it�s a matter of how the dollars are spent and the return on those expenditures and the value that�s created.

There are a number of different ways that we employ to seek to measure our performance. We�ve implemented a process called the balance scorecard, now widely used, I think, in the private sector and also in government, but it has a set of metrics or measures for different elements, whether it relates to customer satisfaction, service, clinical quality, or things that would relate to the money side; our efficiency and productivity.

So we have a scorecard of about 25 to 30 different measures, and we look at that every month, and we evaluate whether we think we�re in the red or the yellow or the green category. Green being good and red being bad and yellow being somewhere in between, and that helps us keep on track for meeting our goals. So we continually are raising our targets with respect to things like customer satisfaction. We regularly measure satisfaction among our beneficiaries, both with the health plan and with the care side, and it�s our goal to continually improve that satisfaction and to make determinations as to why people are not -- if they�re not satisfied, you know, what is driving that and then how do we fix it?

So it�s a process of what I call continual improvement. It�s certainly a process that I employed in my private sector leadership experiences, and I think it works.

Mr. Perry: DoD doesn�t live in a vacuum, and it�s my understanding you worked closely with the Veterans Administration, specifically on something called the Joint Strategic Planning Initiative?

Dr. Winkenwerder: Yes.

Mr. Perry: Would you be able to enlighten us on that, please?

Dr. Winkenwerder: Absolutely.

The relationship between the Department of Defense Military Health System and the Veterans Administration, or the VA Health System, is very important. We have, in my judgment, a very productive and collaborative relationship that�s grown stronger over the last couple of years because of a formalized process that we�ve established to meet, involving the senior leadership of the VA Health System, Dr. Bob Roswell, who�s the Under Secretary for Health and myself, and then even people more senior; the Deputy Secretary of the Veterans Administration formerly was Leo MacKay, and then Under Secretary at DoD, Dr. David Chu, for Personnel and Readiness. He is the Under Secretary.

So we have a group that meets regularly. We�ve developed a strategic plan that�s directed towards how these two large systems, who have different missions, ours being the missions that I described; the VA�s mission more focused around care of veterans, obviously not care of active duty and their families, but care of veterans, focused many times on disability and more longer-term and chronic conditions of retirees and that population.

But obviously, there�s overlap, and one of the important objectives of this process is to ensure as best we can a seamless transition between the care and the care system of the military and the VA, and so we�ve undertaken a number of things to improve that transition.

For example, in the area of information, we want to make all of that medical and clinical information that is collected during the course of one�s military service available to the VA so that the VA doctor or clinician doesn�t have to start all over again; that there�s a seamless transfer of information, and we�re beginning to do that.

We also are trying to standardize some of our business practices so that we can coordinate our actions more effectively; paying for services, organizing services, and so forth. And then finally, in certain locations, we�re doing some pilot projects where we actually do a joint venture together or have facilities co-located or use one facility to care for both populations. Obviously, that can�t happen everywhere, but where we do have facilities together, we think it only makes sense to figure out how we can coordinate between us and really utilize the assets of both systems more effectively rather than being duplicative, and the Congress has taken an interest in this.

The President, I might add, was very interested in this whole issue and had convened early in his tenure a commission on veterans health care that issued a report a few months ago commending us to -- or suggesting, I should say -- that we move in many of the directions I just described, and so their work was helpful. They worked with us, the commission members did, and so that�s where we�re headed, and I think we�ve made a lot of progress. There�s more opportunity ahead.

Mr. Lawrence: During the last TRICARE conference, General Peake spoke of the importance of patient-centric infosphere. Could you explain this to us?

Dr. Winkenwerder: General Peake is the Surgeon General of the United States Army, and I think he was referring to the fact that the focus of our care and care system needs to be on the patient. In other words, thinking about what does a patient need for this concern or this illness or this condition, looking at the system through the eyes of the patient.

We as doctors sometimes have a hard time understanding how the patient is seeing things, and so much often is taken for granted because of differences in knowledge or understanding of what the patient is going through. And that was what General Peake was talking about, and I think the Army Medical Corps, under his leadership, is taking a number of important steps to enhance that patient-centric focus, and that was the thrust of his comments.

Mr. Perry: You mentioned the Army. Each of the three Services seem to be moving in a certain direction. Have those particular Services introduced any new technology that would help you capture this longitudinal medical record that you spoke about before?

Dr. Winkenwerder: Absolutely.

All three Services are working together and will be utilizing this one computerized, electronic record that I described earlier. In the deployed situation, each of the Services has developed a separate system, but producing much of the same information to monitor peoples� health when they�re in the deployed environment. The Army has a system, the Navy has a system, the Air Force has a system, but what we�ve been able to do is to pull the data from all of those three systems together to create a uniform database of information.

We implemented that in an electronic format, and we implemented that on an initial pilot basis for the first time last January with the Iraq conflict, and so for the first time, we had electronic information that was medical surveillance information. In other words, things like what were the rates of certain conditions, whether it was a gastrointestinal illness or a fever or different injuries, et cetera, across the forces that were deployed. And this is more than just a help to the medical people; it can be a help and an early clue for a commander of all those forces to know that something�s not going right. And the system was implemented for both of those reasons.

We were sensitive obviously at that time about the possibility of use of chemical or biological weapons, and so this type of surveillance system is one capability that could give an early warning, and we were glad to be able to implement it on a limited basis. We�re seeking to expand that. We will expand it in the months and years ahead.

Mr. Lawrence: Rejoin us in a few minutes as we continue our conversation with Dr. William Winkenwerder of the Department of Defense. This is The Business of Government Hour.

(Intermission)

Mr. Lawrence: Welcome back to The Business of Government Hour. I�m Paul Lawrence, and this morning�s conversation is with Dr. William Winkenwerder, Assistant Secretary of Defense for Health Affairs, in the U.S. Department of Defense.

Well, Bill, throughout our conversation, we�ve talked about Iraq, but I�m curious: How are things going out in the field?

Dr. Winkenwerder: Well, obviously, it�s a challenging situation in some quarters, but I would also note that there�s been tremendous progress in others, and that often doesn�t get as well-reported.

From the standpoint of our care to our troops and how they�re doing, I think it�s been absolutely outstanding. There�s no question but that lives continue to be saved because of techniques and new doctrine, new approaches that have been introduced just over the last few years.

For example, we now have teams of surgeons who are very close to where the action is. We call it far forward, rather than, you know, miles and miles away in a large field hospital. They�re very close. And through the combination of care that the medic can provide and things like the Quick Clot and other techniques, we�re seeking to operate more quickly to have life-saving surgery, and then to put those individuals on aeromedical evacuation assets, helicopters, the like, and then they�re taken to more definitive tertiary care, either in Germany or back to the United States. And so it�s not unusual that someone might be injured, stabilized with surgery; stabilized in the field hospital for a day or two, but then be back in the United States within three or four days. So that�s a very different approach than the past. It�s leading to, I think, some tremendous saves.

The other element of this that�s very important and I think is a very much better job that�s been done versus the first Gulf War and prior times with respect to just prevention and looking at the environment within which we�re operating, taking preventative measures to avoid illnesses or conditions that can come about as a result of environmental exposures or the like.

We follow a statistic that�s called disease and non-battle injury rates. So that�s basically sickness or injuries, and despite Iraq being one of the most austere environments, in certain places in Iraq, than you�ll find anywhere in the world, our rates are the lowest that they�ve ever been. So we�re pleased about that. That�s a testament to the really quality care that people are getting.

I�ve been to Iraq and visited with our troops and with those that did end up in our medical care system, and that, to a person, they�ve just said the care�s been excellent, and that�s very gratifying. You can�t pull that kind of response out of somebody if it�s not in fact happening. So I commend really all the Service components. Today, the Army is playing the major role on the ground and they�re doing a great job. So I think that all of that�s going well.

On a separate front, our office, my office and others, are assisting the Ministry of Health in Iraq to reconstitute itself and to reconstitute the health care system for Iraq, and we supported the deployment of a senior advisor to the minister of health, and that�s Mr. Jim Haverman, who is formerly the state health director for the State of Michigan. He has been there with a team of about 35 or 40 people now for almost six months. They�ve been doing a terrific job helping to rebuild the health care system in Iraq, and there are many more funds and dollars that are being spent to rebuilt hospitals and clinics and to get the system back working again.

Saddam Hussein basically starved the health care system; grossly underfunded it, used health care to punish certain populations of people, and in many ways, it was very corrupt. But many of those problems, working together with the Iraq medical community, are now being overcome and we�ve not had any epidemics there. We�ve not had any serious disease outbreaks, and in spite of all the terrible events that have happened with the bombings, people in those situations have gotten very good emergency medical care, and that�s a testament to the fact that the system there is working.

So we think that that�s a success.

Mr. Perry: You mentioned some challenges in Iraq. Over the next five years, what other types of challenges do you face?

Dr. Winkenwerder: Let me talk about two or three of them.

The first I would say is continuing to implement change within a large system. Secretary Rumsfeld has identified the need for all of the military to be faster, more flexible, more mobile, worldwide; take on different kinds of missions. The medical piece of that has to take place, and so we need to be, in terms of providing that medical support, the terms are lighter, faster, more interoperable. That means that certain capability that the Navy might have could be used by the Army or Army by the Air Force and so forth; that there�s this ability to exchange teams and units and that kind of thing for different kinds of missions to operate more jointly. And we saw the power of that joint kind of operation in the war phase, and much of that continues now. The same applies in medicine. So I�d say that�s a principal challenge for us.

The second challenge is going to be the cost of what we do; the rising cost of health care, and our private system, our everyday, you know, health care system, that�s costing more. We have an excellent benefit, a very rich benefit, and certainly one of the things that we�ve got to be mindful of is how does that benefit compare to other benefits in the private sector in keeping some level of consistency there so that the long-term costs are manageable.

And then finally, it�s always critical for any organization to continue to attract and retain quality people. The system is the people, and I�m confident that we�ll do that. We continue to get great, young, kids who just want to serve their country, and they�re doing a terrific job, just terrific job, and so I think we�ll meet that challenge, and I think we�ll meet all of those challenges in the days ahead.

Mr. Perry: What role do you see Health Affairs playing in the war on terror?

Dr. Winkenwerder: Well, I think we have been playing a role in the ways I just described; supporting all of our military and in their operations. I would also note another element that we�ve not talked about, and that�s the whole area of biological defense. We�re quite involved in that.

As you may know, we have implemented successfully vaccination programs for Anthrax, to protect our service members against the threat of Anthrax, and also smallpox, and large numbers of our service population are now protected against those two threats. There are other threats that are out there.

So we�re involved in research on that, and we�re working, I think for the first time, in a very collaborative, cooperative way, with the Department of Health and Human Services, with the National Institutes of Health, with the CDC, with the FDA and others. And so the President�s legislation that he proposed, called Bioshield, that will appropriate about close to $6 billion, I believe, over the next five years to be spent to procure or to buy new medical countermeasures against some of these threats.

We�re working with the civilian sector on all that. We see the challenge as being how to protect all of America, not just for us, the military or not just for them, the civilian population, but how do we work together.

And so we have ongoing research, and we�ve worked to try to make that more collaborative, to have the civilian side build on what we�ve done at the Defense Department, because we�ve been involved in some of this for longer, and I think it�s been a great relationship and that will continue.

Mr. Lawrence: You�ve had a very interesting career that has involved two stints in government, so I�m curious, what advice would you give for someone thinking about a career in public service?

Dr. Winkenwerder: Oh, I think it�s a great career option, either as a full-time, permanent career option, or for a stint in public service, appointed service, or volunteering. I just think there are so many experiences that one cannot get any other way. First, you meet great people. You get to work with great people. Some of the challenges you face are so important, and it�s about providing the best that you can for the people that you serve and ultimately for the American people. So I think for those people who like mission-oriented types of jobs, you can�t beat it.

So my public service time has been very gratifying, and I�d certainly encourage young people -- in particular, young people -- to think about that for their future.

Mr. Lawrence: I�m afraid that�ll have to be our last question, Bill. Thank you for joining us today. Mike and I want to thank you.

Dr. Winkenwerder: Thank you very much.

If you�re interested to learn more about us in the Military Health System or what we do, you might want to try to contact us through our website at www.tricare.osd.mil. We can also be reached at www.militaryhealthsystem.osd.mil, and that�s M-I-L. And for some of our beneficiaries, certainly you�re free to call us through our 1-877 numbers, through our service centers around the country.

Mr. Lawrence: Thank you very much.

Dr. Winkenwerder: Thank you. It�s been a pleasure to be here.

Mr. Lawrence: This has been The Business of Government Hour, featuring a conversation with Dr. William Winkenwerder, Assistant Secretary of Defense for Health Affairs, in the U.S. Department of Defense.